Discussing moral injury in medicine.
Dr. Wendy Dean and Dr. Adam Brown provide the diagnosis and prescription for an increasingly common problem in medicine.
Imagine doing work that conflicts with your values. Worse, the problem stems from structural problems of the system you’re working in. Maybe at first you could compartmentalize things, but eventually that friction would eat away at you. Over time, this all might cause more emotional distress than you realize. This concept has a name: moral injury.
You wouldn’t think that moral injury and medicine go together. In fact, on some level, for me, the decision to go into medicine was an affirmative move away from the problem. The thought was, “I’ll be making an honest living by helping people in need? Sounds good.”
The problem is that physicians are no longer as autonomous as we once were. But again, my personal decision to become an emergency physician (particularly in an academic center) perceived that lack of autonomy as a feature, not a bug. I did not want to have to run my own little business. I did not want to have financial incentives nudging me towards more procedures, more tests, and more expensive medicines. I got what I wanted. Yes, some small percent of my yearly bonus is based on my “clinical productivity,” but the difference in what I’d take home is so minute, that I don’t even think about it. (In fact, my goal is to be in the middle third among my peers; I don’t want to be inefficient, nor be that doc who rushes to see more patients than is truly safe and who orders unnecessary MRIs on each of them. I’m happy in the middle on this one!)
That said, one problem with decreased physician autonomy is that sometimes we are forced to do things that do run afoul of our values and best intentions. This puts us at risk of sustaining moral injury.
But, as I learned, it’s more than just confronting competing interests.
Here’s an example from a conversation I had with two experts on this topic for Medpage Today. If I’m giving bad news to a patient or a family and I’m called away to attend to another sick patient who needs immediate attention, that may or may not be an example of moral injury. If the reason I had to cut an important conversation short is that my hospital has chosen to understaff the ER, we’re potentially looking at moral injury caused by my employer (or the pressures of the system). But if the reason was that there was a multiple-victim trauma coming in, well, that sucks, but that’s just life. The crux, according to one of my expert guests, Dr. Wendy Dean, is whether the “medical system” forced me to make emotionally arduous choices that could have been prevented, had the needs of patients and clinicians been centered, rather than, say, economics.
If the name Dr. Wendy Dean rings a bell, it’s because she was a focus of a recent and widely-read New York Times article about this topic, entitled “The Moral Crisis of America’s Doctors.” (I briefly discussed this piece in Inside Medicine.)
Last week, I was joined by Dr. Dean and Dr. Adam Brown to discuss this topic live on Instagram. A nicely edited version of our conversation with transcript is available over at MedPage Today. (Big thanks to Emily Hutto over at Medpage, who takes what are interesting 30-minute chats, and manages to tighten them into a high-impact more digestible permanent format, clocking in at eleven minutes in this case. It’s time well spent.)
Here are some key takeaway points:
More clinicians have experienced moral injury than you might realize. But we don’t have to suffer alone; if clinicians voice concerns collectively (or amplify those of others), it has a greater impact than individuals speaking out in isolation.
Even administrators experience moral injury. Many people in the C-suite entered their roles with genuine intentions of improving healthcare. So when moral injury in medicine occurs, it gnaws at them too.
Clinicians need to communicate challenges from the frontline of medicine to healthcare administrators, especially those without a direct healthcare background.
Changes in autonomy have been a significant factor in clinicians' risk of moral injury in recent decades.
Incorporating patients into the conversation is essential; patients are, in reality, the central stakeholder, and that demographic eventually encompasses everyone, including clinicians.
Please check out this important conversation and let me know what you think in the comments below—whether you believe you’ve encountered this from the patient side (yes, patients can and do experience the moral injury in healthcare that their own providers are enduring) or as a clinician, if you are in the medical or health profession.
When so-called Obama Care was being attacked prior to its initial passage, I was surprised to learn from an essay in the NYRB that there were in excess of a dozen lobbyists in DC for each Congress person and Senator. Each lobbyist was trying to influence the legislators for their respective employers. The AMA had its lobbyists front and center. No one wants to do more work for less money. Eventually, the argument always ends with a comparison of the quality of care in countries with national healthcare versus the care we obtain from our capitalistic system. The overall data comparison is not favorable to our capitalistic system. Capitalism is in our American DNA, and reducing costs will always be at odds with good medical care. It is why medical malpractice insurance exists supported by the Standard of Care for the expert witnesses. It is why the last document you see and are asked to sign before you are wheeled into the operating room is the consent form releasing everybody from the parking lot attendant to the hospital President of any responsibility for a mistake that may occur. Sadly, it is the way things work.
Markets work well for many things but not for delivering quality medical care.